an ounce of prevention.

An interesting thing happened to me a few months ago on a Sunday morning.  I was doing my after church thing…which means my children run around the sanctuary like banshees and pastor Jason is talking to a hundred or so folks and no one can decide what to do for lunch.  It’s a routine of madness.  In the midst of all of that I was approached by a family in our church.  These are people I adore.  They are faithful, they are helpful, they are fun.  Their oldest has started that tortuous time we call middle school.  As a side note there are literally 10 million things I would do over again before middle school.  Like medical school, the last 4 weeks of pregnancy in the Oklahoma heat, 24 weeks of Gyn Oncology service as a resident….middle school seems like the worst thing….but back to the story.

This lovely family had visited their local pediatrician for a routine well child check.  Their pediatrician had appropriately recommend the meningococcal vaccine and the Tdap vaccine (which they happily accepted) and then something strange happened….their pediatrician then asked them to “consider the HPV vaccine…to ask their friends, to read about it, to think and let the doc know what they wanted to do.”  So they came to me to find out “why wouldn’t our doctor want our daughter to have this vaccine?  Is there something wrong with it?  What should we do?”  At this point I am making that face when you are horrified by something…the one with your eyes wide and your mouth open.  And of course I said yes..yes..yes…please go back and get the HPV vaccine series for your child!

If you didn’t know, Human Papillomavirus (HPV) is responsible for about 17,000 cancers a year in women and about 9,000 cancer per year in men.  About half of men and women in the US will be infected with HPV at some point in their life…around 79 million Americans.  Most of those infections occur between ages 19-24 and most of those young men and women will clear the infection on their own without a problem.  So, you might ask, why do we vaccinate against HPV?  Well, we know that almost 13,000 women in the US will be diagnosed with cervical cancer, and 99% or more of cervical cancer is caused by one of the high risk strains of HPV.  4,000 of those women will die of their disease.  Additionally, more than 200 million health care dollars will be spent in 1 year in the US to treat other HPV related diseases such as genital warts.  When you take into account all the screening for HPV related cancer and treatment of pre-cancerous HPV diseases the cost adds up to about 8 billion dollars.  That’s billion, with a B.  Imagine what our health care system could do with those dollars if we would significantly decrease or eliminate the burden of HPV disease through vaccination.

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The vaccine works.  Multiple studies have shown it to be extremely effective.  We’re talking 99% effective against the pre-cancerous changes that I see and treat on a weekly basis to try and prevent my patients from getting cervical cancer.  Right now about 39% of US adolescents are being vaccinated.  The goal is for 80% of those eligible to receive the full vaccine series.  In short, we are doing a terrible job folks.  In contrast, our friends in Australia have a vaccination rate around 75%.  They have virtually eliminated genital warts in those women under the age of 21 and soon will see a dramatic reduction in cervical cancer.

So why wouldn’t all our girls and boys age 11-12 receive the 3 dose HPV vaccine series?  Well,  first of all, our health care providers aren’t recommending the vaccine.  My friends from church have great trust in their pediatrician and have faithfully received all the vaccinations recommended to them.  But the HPV vaccine was not.  If we as health care providers would recommend HPV vaccination along with other routine immunizations for 11 and 12 year olds we could exceed the 80% immunization goal.  What are the barriers to provider recommendation?  Well, there could be several.

Our culture has made the HPV vaccination into a moral argument.  Parents believe that their child is more likely to become sexually active if vaccinated.  This has been proved incorrect in the medical literature over and over and over again.  Kids are no more likely to become sexually active after HPV immunization than they are to go seeking out someone to snuggle up with who has meningitis after being immunized against it at the same age.  We assume that people infected with HPV and those who have HPV related diseases must have done something wrong, behaved inappropriately, had “loose morals” or some other kind of disgusting label such as that.  The reality is that this disease can affect anyone.  Show me someone whose life turned out exactly as they had planned and whose children turned out exactly as they had planned and maybe you have an argument against vaccination…maybe.  But really for all of us, we don’t know what life will bring.  We can’t predict much of what will happen to us or those around us.  As I like to tell the medical students…no one leaves on a plane for  Africa to do some good missionary work with the intention of finding someone with yellow fever and being infected…but we still get immunized before the trip without question.  Immunization against HPV is just the same.

Additionally, our culture loves to believe what we read on the internet (ironically what you are doing right now).  Despite this vaccine being shown by research in the US and multiple studies in Europe to be safe and demonstrate no pattern of serious neurologic or other injury, many in the US are still afraid that HPV immunization will make your child sick or is some kind of conspiracy theory.  Does the vaccine hurt?…yes.  Are adolescents, especially girls, more likely to pass out with this immunization?…sure.  Do all immunization involve a very small likelihood of serious risk?…yes.  But that’s about it.  And those risks are much smaller than the risk you or your child has of being affected by HPV related disease.  Our role as health care providers is to educate and advocate.  If you ask any of my medical students they will tell you how they endured the “all things HPV” lecture during their time on OBGYN.  My hope is that there will be more voices who advocate for HPV immunization and than any loud voice that might tell them otherwise.

Screen Shot 2016-05-30 at 1.19.37 AMSo, health care providers….RECOMMEND the HPV vaccine.  Telling a women she has cervical cancer, treating recurrent genital warts, seeing complication of pregnancies caused by the treatment of HPV related diseases is heart-breaking work.  Trust that your patients will listen to you.  Present them with the truth and advocate for their future health and the health of the people they love.

Parents, pre-adolescents, teens, and those who know or love a parent, pre-adolescent or teen: don’t assume it can’t happen to you.  As Ben Franklin said “an ounce of prevention is worth a pound of cure.”  I hope I have to find something to do with those 20 hours a month I spend screening and treating HPV related disease.  I hope that someday we will speak of cervical cancer and other HPV related diseases like we do of polio.  Ask questions, get vaccinated, tell others.  If you have questions, ask a trusted health care provider.  If they can’t answer them, find another health care provider who can.  You never know who the 4000 lives are that would be saved.

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a voice in the wilderness.

It has been quite a week.  Pastor Jason was involved in all the church Sacrements last weekend.  A funeral, a wedding, a baptism, a dedication and communion.  Which means it was a very. busy. weekend.  So I didn’t get my blog post done on Sunday.  I was a bit disappointed in myself but I just didn’t have peace about the final version.  Well, it got scrapped so here I am with version number 2.  Same title, different content direction.

My first version of this post told a story about Nancy and Mac, who we sat next to at the rehearsal dinner and who were a voice in the wilderness for us.  They spoke into our lives and reminded us that what we do each day has meaning and purpose, that our hard work is not thankless and that there is hope in the future.  And then Monday happened.  Work was work and people were acting a fool.  So the blog post sat.

But today my disappointment for not being done with the blog post “on time” was wiped away by renewed inspiration to be a voice in the wilderness.  If you didn’t know, I live in Oklahoma.  Today, our state passed a bill that makes it a crime for any physician to perform an abortion in our state, except for in the case of the life of the mother.  You must be thinking as a person of faith and a pastor’s wife that I would think this is great news, right?…wrong.  Fasten your seat belts kids, this Jesus loving gynecologist is going to try to explain to you why this is a terrible idea.  It’s going to take a minute, so bear with me.

First, I don’t think we can consider ourselves “pro life” unless we are really going to work to help make a life for those around us.  That means a living wage for all people, enough food for families to eat, prison reform, quality education for all and support for those women who find themselves raising a family alone…not to mention standing up against domestic violence and sexual assault.  And to be pro-life means you support planned and appropriately spaced pregnancies so that they are more likely to have healthy babies and take care of them in the ways we would all like.  It means you believe in access to affordable and reliable contraception for everyone.   Because even if you intend to be abstinent you might find yourself among the 1 in 5 women who is a victim of sexual assault..see previous blog post…needing emergency contraception.  Which, by the way, prevents ovulation…which happens PRIOR to conception, therefore not ending pregnancies, just preventing them.  And if we as the culture, the church or the community are really going to say we are pro-life…then we need to have the guts that two of my close friends did and invite a child from the over-flowing foster care system into your home.

Second, laws like this do not deter women from getting an abortion.  Electively terminating an pregnancy in my state is not easy to do.  Women must have money, transportation, time off of work, family or community support, not to mention navigation of the multiple laws.  So I don’t think adding this one will make a huge impact.  What makes abortion rates go down?  Access to affordable and reliable contraception.  In Western Europe abortion rates are very low, even though it would be easier to have an elective termination of pregnancy there compared to most places in the US.  Why?  They have a high rate of contraception use and a low unintended pregnancy rate.  Furthermore, I disagree with the legislation of reproductive rights.   What would happen if someone made a bill that said I couldn’t have fertility treatments to have my second child? What about a law that says no one can have more or less than 3 kids?  Uh, no thanks.  We think that these laws restricting or outlawing abortion are “good” because abortion is “bad,” but legislating reproductive rights in any way is never good. You just might not see it that way until you are on the receiving end of the law and it doesn’t fit your belief system.

Lastly, physicians don’t practice good medicine when we practice in fear.  In my job and within my belief system I would only be involved in a termination of pregnancy if the life of the mother is in danger.  I make these decisions based on clinical experience, medical evidence and science and standards of care if they exist.  Except…now that I might go to jail if I make the wrong decision will I second guess just what does “exceptions for the life of the mother” mean?  Can I remove the ectopic pregnancy, and therefore terminate the pregnancy, before it ruptures and tries to kill the mother?  Do we deliver the woman with very early and very severe preeclampsia knowing her baby will almost surely die from prematurity before she has a stroke or a seizure or is her life only in danger if one of those happens.  These seem like silly questions but when providers are asked to make decisions with a law hanging over their shoulder threatening to make a criminal out of them it just might impact judgment and decisions.  And that will certainly negatively impact the lives of women in our state.

So what do we do?  Well, it is my hope and prayer that no woman would need to undergo an elective or medically necessary termination of pregnancy (i,e, abortion).  I hope that I will be around to see that world.  But it won’t happen if I don’t do my part.  My solution, for today, was to be a voice in the wilderness.  Mostly, I try not to get myself or the pastor in too much trouble with my tendency to say whatever I am thinking and ask whatever is on my mind.  I will certainly have friends in my church, my Christian community and others around me strongly disagree with this post.  But as Pastor Jon and Jason say, we must find a way to disagree Christianly.  Nancy and Mac, from the rehearsal dinner, were a voice in the wilderness for me.  They weren’t afraid to say what they thought, to listen to us and to tell us that our voices matter.  Today I am a voice in the wilderness for the women and their children in my state.  My state that has no solution for a 25% reduction in state funded healthcare that will leave thousands without access to medical care, a state where the district I live in has a 3.6 million dollar deficit to make up for in education despite having some of the lowest paid teachers in the nation and no art program.  A state where we put more women in prison that almost anywhere else, where we have significant problems with tobacco abuse, obesity, cancer prevention and other community health needs.

Isaiah is one of my favorite books of the Bible.  It is the inspiration for this blog post.   I love Isaiah 40.

Comfort, O comfort my people,
says your God.
2 Speak tenderly to Jerusalem,
and cry to her
that she has served her term,
that her penalty is paid,
that she has received from the Lord’s hand
double for all her sins.
3 A voice cries out:
“In the wilderness prepare the way of the Lord,
make straight in the desert a highway for our God.
4 Every valley shall be lifted up,
and every mountain and hill be made low;
the uneven ground shall become level,
and the rough places a plain.
5 Then the glory of the Lord shall be revealed,
and all people shall see it together,
for the mouth of the Lord has spoken.”

Be a voice in the wilderness today.  I challenge you to think about what it means to be “pro-life” to everyone around you, whether you think like them or not.  The truth is they are loved by God just like you.  Maybe, together, our voices can improve the systems we live and work in so that the valleys can be lifted up, the ground will be leveled and the glory of the Lord will be revealed to the least of these that surround us.  Thanks for enduring with me on this one.

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listen…to…your mother.

Listen…to…your mother.   It’s a phrase I utter about seven thousand times on a Sunday morning.  When I can’t seem to get the girls to find their shoes, brush their teeth, get in the car and a multitude of other things on the way to church I emphatically state “listen…to..your mother.”  They think it’s hilarious to repeat the phrase over and over to each other and giggle about how crazy I sound.

A dear friend said to me this morning: “Mother’s Day..sometimes it just seems like too much.”  And I get that.  Mothers feeling overwhelmed at a day to celebrate them, yet unable to escape the responsibilities of the daily routine.  Women who wish they were mothers but are unable.  Women who mourn the loss of their child or their own mother.  Families who need reconciliation on these celebratory days.

So what to write about on this “too much” day.  After much thought (kidding…I was napping this afternoon), I thought I would make a list of what your mother would want you to know if she was an OBGYN married to a Pastor.

  1. Educate your kids about their bodies: My kids remind each other to “wash around your vagina” in the tub.  When BK was born, Mc said breastfeeding was “weird.”  To which I replied, “yes dear, it’s only the beginning of weird stuff your body does.”  Kids who know how their bodies function can express when they are injured, uncomfortable or, God forbid, touched inappropriately.
  2. Vaccinate your kids against HPV: People, it’s not a conspiracy theory.  It’s a vaccine that has the potential to eliminate or nearly eliminate cervical cancer and significantly reduce HPV related diseases.  Trust me.  I deal with this, literally, every day.  Does every vaccine have a small risk of complications?  Yes, but significantly less likely than me seeing your kid later in life for an abnormal Pap test or some other problem.  Plus, there’s more formaldehyde in pears and bacon than in vaccines. (mic drop).
  3. Make sure your kid has a trusted adult they can talk to that’s NOT YOU.  As parents we think we want or need to know everything that is happening in our kids lives.  The reality is that we can’t do much about it.  I can tell you everything your kid says to me in the office but then she wouldn’t trust me and she already doesn’t listen to you.  What I can do is encourage them to be safe, be healthy, see the consequences of their actions before they happen and be honest with you.  So make sure they have a pastor, a doctor, a coach or a mentor you trust.
  4. Let your kid be honest with you.  When they do something dumb and are brave enough to tell you about it be sure to remind them how glad you are they were honest with you amidst the lecture about how disappointed you are.
  5. And finally, be easy on yourself.  I am reminded weekly by Pastor Jon and Pastor Jason that God has already made His mind up about you and the news is good.  It’s okay to be stressed, sad or overwhelmed on Mother’s day.  Or any day.  Forgive others, forgive yourself.  Love people more than they deserve and let yourself be loved more than you deserve.  And don’t forget to see your Gynecologist and go to Church.

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1 in 5.

DISCLAIMER: This post contains a topic that may trigger difficult emotions for some people and the content is what I would describe as “mature.”  No explicit language is used.

I have previously posted a blog titled “1 in 3” on domestic violence.  This blog focuses on another horrific statistic in our nation, the rate of sexual assault against women.  1 in 5 women is a victim of sexual assault.  1 in 5.  In the US.  I’m not kidding.  Not something you see advertised, right?  About a third of these women experience assault or sexual violence during their college years. Also not advertised.  The most common perpetrator in these situations is someone the victim knows, such as a current partner, family member or someone else they know.  Contrary to what most people think, only about 13% of sexual assault is committed by a stranger.  We obsess over who is using our bathroom but ignore the violence perpetrated by family and friends.  Over 30,000 children are born as a result of rape in this country annually.  Shocking, I know.  These women are often broken in so many ways and are now charged with the difficult duty of raising a child.

The CDC uses the term “sexual violence” and this includes a wide spectrum of attempted or completed unwanted sexual behavior.  They utilize multiple data sources to track sexual violence in the US and find out what prevention programs are useful as well as identify risk factors for assault.  It is interesting to carefully look at the factors associated with sexual violence.  And while none of these can directly be correlated (that is, no single or combo of these behaviors or situations guarantees you will be a victim) there isn’t much surprise in this list.  Many of those risk factors are community and society related such as poverty, weak community support, tolerance of sexual violence and societal norms that view women as inferior to men.  As you can imagine sexual assault has very serious and very long consequences.  There are physical and psychological consequences, but women who are victims often are more likely to engage in behaviors that have negative consequences for themselves and the community around them.

Why should we care and what should we do?  Well, we should care because we have daughters, sisters, aunts, mothers and other women in our lives who might experience sexual violence.  We should also care because our society deserves better.  I believe we are ill-equipped to deal with sexual violence in our high schools, our college campuses and in our homes.  In the last 3 months I have read several articles about universities that are under investigation for their handling of sexual assault cases.  In many of these, the perpetrators have been accused multiple times and in some cases have transferred schools and found other victims.  We must do better.

Many prevention programs focus on education about sexual violence, improving bystander intervention and helping people understand what consent means.  Unfortunately, these programs are underutilized.  Why?  I don’t have all the answers, but I will tell you what I think is happening.  First of all, we avoid discussing sexual behavior in general.  Second, we think that telling people not to have sex is the answer.  Until we begin to have the hard discussions with ourselves and our children about how our bodies work and normal sexual behavior we don’t have a context in which to educate young men that sexual violence is absolutely unacceptable.  We need to teach our children what it means to love and respect one another, as well as what it means to not standby when others are victimized.  We live in a culture where sexual assault is more likely to be videotaped and placed on social media than someone actually trying to intervene or help a victim.

Let’s all do better on this one.  If you have kids, make sure they understand what it means to love and respect themselves and the other gender.  If you know someone who has been victimized, don’t blame them for what happened.  If you work at a church, university or another large organization with young people, find out what, if anything, you are doing to address the problem of sexual violence.  If you see something, say something. Maybe we can make a difference and change this statistic. From my life with the pastor I am reminded of my charge to care for the orphan, the widow and the sojourner…the 1 in 5 is in the midst of these.  Let’s help them.

http://www.cdc.gov/ViolencePrevention/sexualviolence/index.html